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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {2091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 150 Job Address li2_1.6 1y�CJw�[� � I� �� City ` 00 If Lot Size PM Owner's Name C Jr c� 7 Address 9^vt Phone Contractor _,.'—C� _ _Address" License No. 0 57 2-/ Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT D DESTRUCTION ❑ PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public Cl Other D'Delta Depth of Grout Seal Type of Grout- I 1 Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION INr DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.l �� } installation will serve: Residence ✓ Commercial— Other Number of living units: � Number of bedrooms �p p Character of soil to a depth of 3 feet: C Ora M _ Water table depth < " SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal wa. ` Distance to nearest: Well Foundation . Property Line 1 _ 1 LEACHING LINE � No. & Length of lines _e/_ S �` Total length/size } r FILTER BED ❑ Distance to nearest: Well . Foundation 3© 1 Property Line a2 S 1 SEEPAGE PITS 1-1' Depth Size t� Number �- SUMPS Ll Distance to nearest: Well O' t o2 x -�y Foundation 7� Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is isued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiringor Sub-con i�(jacting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to work rjlan's compensa- tion laws of California." 1 1 The applicant must call for all required inspections. Complete drawing on reverse side. p Signed X— ��r Title: G£A�i.'6f.� _ Date: /s d FOR DEPARTM T USE ONLY Application Accepted by �~ ate '` Area12 `p , f Grout Inspection bY,o m � 2 Final Inspection by ati ditionat❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24{REv.t i H 51O 0 0 �1 ® 1 �1 3n t EH 14-29 0 d` f � V- V f _ J